Pacemaker malfunctions are a not-infrequent reason for an emergency department evaluation. As a result, there is a wide differential into the underlying potential etiologies.
Case Summary
A well-appearing 81-year-old female with a past medical history of hypertension and cardiac pacemaker placement 9 months prior for dysrhythmia presents to the ED complaining of hearing a “beeping sound” from her cardiac pacemaker. She states that while in a meeting, she noticed multiple episodes of this beeping sound, without any complaints such as chest pain, shortness of breath, syncope, cough, fever, or chills. She denies any previous complications with her pacemaker, stating all has been well since placement at an outside hospital. Her vital signs are: 97.6 F, HR 66, BP 133/62, SaO2: 99% on room air, and RR of 16. Her physical exam is unremarkable, with obvious pacemaker to left chest.
Learning Points
Pacemaker malfunctions are not an infrequent reason for an emergency department evaluation. As a result, there is a wide differential into the underlying potential etiologies. Patients can present with problems regarding the pacemaker itself, commonly involving battery failure. Other potential etiologies may be secondary to a regional problem, such as surrounding infection or hematoma. These conditions are more commonly seen directly following placement.
The pacemaker itself can also have problems secondary to lead separation, dislodgement, or coiling. In rare cases the pacemaker can cause local trauma, leading to thrombus formation or myocardial rupture. When these types of problems occur, they often lead to downstream electrical problems, such as failure to capture or pace.
Thorough history-taking is vital in these patients, as external interference can also occur. The National Institutes of Health recommends against extended exposure in close proximity to objects such as cellular phones, household appliances such as microwaves, high-tension wires, metal detectors, industrial welders, or electrical generators because these objects can disrupt signaling and cause dysfunction. Some recent literature also supports that cellular phones cause no disruption, and that a pacemaker will only alert airport security to a metal device, but have no risk of dysrhythmia. Almost all pacemakers are appropriate for MRI testing, but it is recommended that the patient’s cardiologist is contacted prior to testing. If a patient requires cardioversion, it is recommended that cutaneous pads are placed anterior-posterior, with at least 8 cm between pads and patient’s pacemaker.
Case Resolution
After it was determined that the patient was stable, requiring no acute interventions, pacemaker interrogation was performed. The generated report from the supplier displayed that the patient’s pacemaker had gone in and out of “magnet mode” multiple times just prior to her arrival. The patient had no acute events of dysrhythmia.
On further questioning, and in an effort to investigate for electromagnetic interference, it was found that the patient was wearing a magnetic nametag over her left chest while in a meeting. Her nametag had already been removed, and her pacemaker was no longer in magnet mode and acting appropriate. After appropriate counseling, she was discharged to follow up with her cardiologist and avoid any potential objects that can cause electromagnetic interference.
References
1. National Institute of Health: National Heart, Lung, and Blood Institute. Health Topics/Pacemakers. https://www.nhlbi.nih.gov/health-topics/pacemakers.
2. Bernstein AD, Daubert JC, Fletcher RD. The revised NASPE/BPEG generic code for antibradycardia, adaptive-rate, and multisite pacing. North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group. Pacing Clin Electrophysiol. 2002;25(2):260-264.
3. EB Medicine. Managing Pacemaker-Related Complications and Malfunctions in the Emergency Department. 2014.